c
 

‡ Personal habits
‡ Chief complaint
‡ Medical history
‡ Dental history
‡ Examination
General
Extra oral
Intra oral
Occlusal
Radiographic
Vitality tests
R
 
c  
 


 r
J Effect depends upon intercuspation
of teeth on either side of space with
those of opposing arch
J Age and periodontal condition
J Tooth movements depend upon
position of tooth in arch
¦ lower molars tilt mesially
2 upper molars tilt mesially and
rotate around palatal root
3 the premolars stay upright and
move bodily into any space
!

   



Over eruption leads tor

¦
oss of bony support for tooth

2
Overgrowth of alveolus
3
Traumatic occlusion
4
oss of contacts which leads to
food impaction
periodontal
breakdown and subgingival caries
J ^ailure to maintain
space after tooth
extraction can lead
to tooth movement
unless this is
prevented
J The teeth may tilt
into the space or
an opposing tooth
may over erupt
J Either can result in
functional
excursions and
periodontal
destruction
j

 

 

‡ Esthetics
‡ ^unction
‡ Pain due to TMJ dysfunction
‡ Speech
‡ Maintenance of dental health
V

c


‡ The patient¶s name,age,sex,
address, phone number,occupation,
and marital and financial status are
noted

‡ In addition to establishing rapport

and developing a basis for the
patient to trust the dentist, small
and seemingly unimportant
personal details often have
considerable impact on establishing
a correct diagnosis, prognosis, and
treatment plan

Ô
Ô 


J This is the reason ,usually a

symptom or a cluster of symptoms
why the patient seeks treatment
J It can be urgent ,such as acute pain
,or gross swelling or minor
complaint

J The chief complaint should always
be noted and addressed because it
is generally the reason why the
patient sought care in the first place
J All findings are grouped as either
symptoms (subjective ,elicited by
history and interview as described
by the patient or signs (objective
often measurable ,discovered by
examination
 Œ!
V w this acronym often seen in
medical and dental notes
J S= Subjective (symptoms elicited
by patient
J O= Objective (signs discovered by
examination
J A= Assessment (analysis of the
information- the diagnosis
J P= Plan (what you intend you do
about the problem
Chief complaints usually fall into one
of the following four categories

J Comfort (pain, sensitivity, swelling

J ^unction (difficulty in mastication or
speech
J Social (bad taste or odor
J Appearance (fractured teeth or
restorations, discoloration

 Ô 

‡ If pain is present, its location,

character, severity, and frequency
should be noted, as well as the first
time it occurred, what factors
precipitate it (e
g
, hot, cold, or
sweet things , and any changes in
its character
Is it localized or more
diffuse in nature ?



 

Difficulties in mastication and

speech may result from a fractured
cusp or missing teeth

It may also indicate a more
generalized malocclusion or
dysfunction

Œ


A bad taste or smell often indicates

compromised oral hygiene and
periodontal disease

Often social pressures prompt the
individual to seek care

V






Compromised
appearance is a
strong
motivating factor
for patients to
seek advice as
to whether
improvement is
possible
J Such individuals may have missing
or crowded teeth or a tooth or
restoration may be fractured

J Their teeth may be unattractively
shaped, malpositioned, or
discolored, or there may be a
developmental defect

 


 
  

‡ An accurate and current general

 
   should include any
medication the patient is taking as
well as all relevant medical
conditions
If necessary, the
patient¶s physician(s can be
contacted for clarification

The following classification may be
helpfulr

Ô  

 







J Any disorders that necessitate the
use of antibiotic pre medication
J Any use of steroids or
anticoagulants, and any previous
allergic responses to medication or
dental materials
J Once these are identified, treatment
usually can be modified as part of
the comprehensive treatment plan


Ô  

  







J Previous radiation therapy
J Hemorrhagic disorders
J Extremes of age
J Terminal illness
^or instance, the patients who have
received radiation treatment may
suffer from xerostomia,which is
conducive for greater carious
activity and hence extremely hostile
for cast metal restorations

They are also more susceptibility
for infection following injury and
delayed healing
J Patients with prosthetic valves are
on Coumadin ,an anticoagulant

J Thus any procedure which may
induce even minor bleeding should
be prevented

J Patients who are
immunocompromised are more
susceptible to opportunistic disease


Œ
 Ô   with oral

manifestations
J Periodontitis may be modified by
diabetes mellitus, menopause,
pregnancy, or the use of anticonvulsant
drugs
J In case of hiatal hernia, bulimia, or
anorexia nervosa, palatal surfaces of
teeth may be eroded by regurgitated
stomach acid
J Certain drugs like anticonvulsants leads
to hyperplasia of gingiva
J Patients with compromised immunity
‡


cR

 
Œ
!j

Clinicians should be cautious when
commenting before a thorough
examination is completed

J Periodontal history
J Restorative history
J Endodontic history
J Orthodontic history
J TMJ dysfunction history
V
 
  
JThe patient¶s oral hygiene is
assessed
JCurrent plaque-control
measures
JThe frequency of any previous
debridements should be
recorded the dates and nature
of any previous periodontal
surgery should be noted

j


  may include
JOnly simple composite resin
JDental amalgam fillings,
JIt may involve crowns and
extensive fixed partial dentures

JThe age of existing restorations
can help establish the
prognosis and probable
longevity of any future fixed
prostheses

R  
JThese can be readily identified
with radiographs

JThe findings should be
reviewed periodically so that
periapical health can be
monitored and any recurring
lesions promptly detected
!  
J Occlusal analysis should be an
integral part of the assessment of a
post orthodontic dentition

J Occlusal adjustment (reshaping of
the occlusal surfaces of the teeth
may be needed to promote long-
term positional stability of the teeth
and reduce or eliminate
parafunctional activity

JOn occasion, root resorption
(detected on radio-graph may
be attributable to previous
orthodontic treatment

JAs the crown / root ratio is
affected, future prosthodontic
treatment and its prognosis
may be affected

 c    
J A history of pain
J Clicking in the temporomandibular
joints
J Neuro-muscular symptoms such as
tenderness to palpation, may be
due to TMJ dysfunction,
J Which should be normally be
treated and resolved before fixed
prosthodontic treatment begins

V

 

 

Ñruxism
‡ Ñite Discrepancy
‡ Psychological Triggers
‡ Chemical Triggers
‡ Intake of ³uppers´ such as
caffeine and amphetamines
synergistically enhance the
contractions of the jaw muscles
‡ Hence the use of these drugs
can bring about rigorous
clenching and grinding
‡ Certain prescription drugs like
the anti-depressant, Zoloft is
known to induce Para function

c
 


 
‡ Much like diagnosis of many other
diseases, there are no ³litmus tests´
for this condition






^ront to back fracture of the lower
molar
2
Morning headaches in the
temporal areas

3
May suffer from stiff neck and
shoulders

4
May find the teeth to be sore,
especially upon awakening

J

 

 
Abfraction is a condition in which
the neck of the tooth is eroded
away in a chemical reaction as it
flexes under clenching and grinding
forces

J As a result of this, the dentinal
surface becomes exposed and that
area becomes extremely sensitive

‡ Sensitive areas on the neck of teeth
are usually indicative of severe
clenching
J Excessive wear
facets that are flat
and shiny on the
top of the back
teeth, inconsistent
with the age of
the individual, is a
sign of grinding

J Thinning and
chipping of the
front teeth is
another sign of
excessive wear
from grinding

J ^ormation of
extra bone
around the teeth,
most commonly
on the inside
surfaces of the
lower premolars

J Previously these
bone formations
that are called
³tori´ were
thought to be of
genetic origin

J Scalloped
tongue is a sign
of continuous
clenching
accompanied by
pressing on the
teeth by the
tongue

R


!
J An examination consists of the
clinician¶s use of sight, touch, and
hearing to detect conditions outside
the normal range

J To avoid mistakes, it is critical to
record what is actually observed
rather than to make diagnostic
comments about the condition

J ^or example, ³swelling,´ ³redness,´
and ³bleeding on probing of gingival
tissue´ should be recorded rather
than ³gingival inflammation´ (which
implies a diagnosis



 R

 

J Emergency examination
J Screening examination
J Comprehensive examination


 
 


 

J Inspection
J Palpation
J Percussion
J Auscultation
J Olfaction
Examination
J General
J Extra oral
J Intra oral
—


 R

 
J The patient¶s general appearance,
gait, and weight are assessed

J Skin color is noted for signs of
anemia or jaundice

J Vital signs, such as respiration,
pulse, temperature, and blood
pressure, are measured and
recorded

J ^ixed prosthodontic treatment is
often indicated in middle-aged or
older patients, who can be at higher
risk for cardiovascular disease

J Patients with vital signs outside
normal ranges should be referred
for a comprehensive medical
evaluation before definitive
treatment is initiated

R 

 R

 

J ^acial symmetry

J Cervical lymph nodes are palpated

J


 
  

Tenderness, or pain on movement,

is noted and can be indicative of
inflammatory changes in the
retrodiscal tissues, which are highly
vascular and innervated

 J TMJ can be

 located by

palpating
bilaterally just
anterior to the
auricular tragi
while having the
patient open and
close

J This permits a
comparison
between relative
timing of left and
right condylar
movements

J If there is evidence of significant
asynchronous movement or TMJ
dysfunction, a systematic sequence for
comprehensive muscle palpation should
be followed as described by Solberg and
Krogh-Poulsen and Olsson

J Each palpation site is given a numerical
score based on the patient¶s response

J If neuromuscular or TMJ treatment is
initiated, the examiner can then re
palpate the same sites periodically to
assess the response to treatment
JA maximum
mandibular
opening resulting
in less than
35mm of
interincisal
movement is
considered to be
restricted,
because the
average opening
is greater than
50mm

J Similarly, any
midline deviation
on opening and or
closing is recorded

J The maximum
lateral movements
of the patient can
be measured
(normal is about
¦2mm
 
 
 
 
J Palpated for signs of tenderness

J Palpation is best accomplished
bilaterally and simultaneously

J This allows the patient to compare
and report any differences between
the left and right sides

J ight pressure should be used (the
amount of pressure one can
tolerate when gently pushing on
one¶s closed eyelid without feeling
discomfort is a good comparative
measure ,
J If any difference is reported
between the left and right sides, the
patient is asked to classify the
discomfort as mild, moderate, or
severe
 
J The patient is observed for tooth
visibility during normal and
exaggerated smiling

J This can be critical in fixed
prosthodontic treatment planning,
especially for margin placement of
certain metal ceramic crowns

J Some patients show only their
maxillary teeth during smiling

J More than 25% do not show the
gingival third of the maxillary central
incisors during an exaggerated
smile
J The extent of the smile will depend
on the length and mobility of the
upper lip and the length of the
alveolar process

J When the patient laughs, the jaws
open slightly and a dark space is
often visible between the maxillary
and mandibular teeth This has been
called the 
 

J Missing teeth, diastemas, and
fractured or poorly restored teeth
will disrupt the harmony of the
negative space and often require
correction
‡ ips are inspected
,palpated bimanually
and bilaterally then
reflected to reveal
labial mucosa


j
!j
 R


!
J The intraoral examination can
reveal considerable information
concerning the condition of the soft
tissues, teeth, and supporting
structures

J The tongue, floor of the mouth,
vestibule, cheeks, and hard and
soft palates are examined, and any
abnormalities are noted

JÑuccal
mucosa
including
the parotid
duct and
typical
linea alba

JThe tongue
presents a
wide range of
normal in a its
size shape
and surface
texture

J The dorsum
should be
examined and
palpated till the
circumvallate
papilla
retraction of
the tongue is
necessary in order
to visualize the
area,which
represents a
relative high
incidence of oral
JThe ventral
aspect is
appreciated for
the lingual
frenum ,typical
varicosities and
submandibular
salivary glands
J ^loor of the
mouth is
palpated
bimanually with
an opposing
thumb or finger
braced under
the
chin,appreciatin
g the salivary
glands and
muscular floor
of the mouth
j
 
j 
Ô
‡ An ideally shaped ridge has a
smooth regular surface of attached
gingiva
‡ Its height and width should allow
placement of a pontic that appears
to emerge from the ridge

‡ oss of residual ridge contour may
lead to unaesthetic open
embrasure(ÑACK
TRIANGES ,^ood impaction and
percolation of saliva during speech
Siebert has
classified residual
ridge deformities
into three
‡ Ô




labiolingually loss
of tissue with
normal ridge
height
‡ Class II
defects w
oss of ridge
with normal
ridge width
‡ Class III
defects wa
combination
of loss in both
dimensions
V
 
 R

 

A periodontal examination should

provide information regarding
JOral hygiene of the patient
JThe response of the host tissues,
JThe degree of irreversible
damage

J Ñecause long-term periodontal
health is essential to successful
^ixed Prosthodontics existing
periodontal disease must be
corrected before any definitive
prosthodontic treatment is
undertaken

— 

J The gingiva should be lightly dried
before examination so that moisture
does not obscure subtle changes or
detail

J Color, texture, size, contour,
consistency and position are noted
and recorded

J The gingiva is then carefully
palpated to express any exudate or
pus that may be present in the
sulcular area

J Healthy gingiva
is pink,
stippled, and
firmly bound to
the underlying
connective
tissue

J The gingival
margin is knife-
edged, and
sharply pointed
papillae fill the
interproximal
spaces

The width of attached gingiva can be
assessed by
‡ Periodontal probe
‡ Injecting anesthetic solution
J In this examination the probe is
inserted essentially parallel to the
tooth and is ³walked´
circumferentially through the sulcus
in firm but gentle steps, determining
the measurement when the probe is
in contact with the apical portion of
the sulcus
J Thus any sudden change in the
attachment level can be detected
?




 






 



 













J Probing depths (usually six per tooth
are recorded on a periodontal chart
which also contains other data pertinent
to the periodontal examination
J Tooth mobility or malposition
J Open or deficient contact areas
J Inconsistent marginal ridge heights
J Missing or impacted teeth
J Areas of inadequate attached keratinized
gingiva
J Gingival recession
J ^urcation involvements
‡ Mandibular third molars frequently
(30-60% do not have attached
gingiva around distal segment
‡ A Prospective abutment that does
not have attached tissue is a poor
candidate to receive a crown

? 













 









? 






















 



 








 




 

? !
"
#




 









? !
$%





 












 

c

 Ô
 
J Dental caries
J Restorations
J Wear facets(indicative of sliding
contact sustained over time and
thus may indicate Para functional
activity
J Abrasions
J ^ractures
J Malformations
J Erosions

‡
Ñefore proceeding with the
restorations an ANASIS of the
occlusion is done and examined forr
J Any TMJ Pain, muscle spasm

J Ease or Difficulty with which the
various excursions can be made
voluntarily by the patient

J Any occlusal interference

J Mobility of teeth during excursion of
the mandible with the teeth in
contact

J Presence, angle and smoothness of

any slide from Retruded Contact
Position to InterCuspation Position

J The type of lateral guidance

J Presence of any contact on the
non- working side

J ocation, extent and cause of any

faceting of teeth to be restored

J Degree of stability of the occlusion

J Overerupted or tilted teeth

interfering with the occlusion

‡ Occlusal
assessment of
restorations

‡ Very thin
articulating paper
is required such
GHM which has
marking ink only
one side thus
keeping it as thin
as possible

‡ The marking ink is transferred from
the paper to the tooth and at any
point of contact ,provided the teeth
are dry
‡ Special tweezers are available for
easier handling
‡ Helps in determining where
premature contacts exist in centric
occlusion

‡ It is worthwhile
while trying w in
of any
restoration, to
establish which
occlusal
contacts exist
between the
patients teeth
when
restoration is
out of the
mouth

‡ If these
contacts are
memorized and
the marks
removed they
should be
repeatable with
the restoration
in place

—



 

J The teeth are evaluated for
crowding, rotation, supra-eruption,
spacing, malocclusion, and vertical
and horizontal overlap

J Teeth adjacent to edentulous
spaces often have shifted position
slightly

J Small amounts of tooth movement
can significantly affect fixed
prosthodontic treatment

J Tipped teeth will affect tooth
preparation design or in severe
cases, may result in a need for
minor tooth movement before
restorative treatment

J Supra-erupted teeth are often
overlooked clinically but will often
complicate fixed partial denture
design and fabrication

j
c
!—j
V
Ô R


!
J Radiographs provide essential
information to supplement the
clinical examination

Detailed knowledge of
J The extent of bone support
J The root number and morphology
J Periodontal condition of tooth
J Periapical pathology
J Retained roots
J Caries
J Restorations



 
 


J


  - standard periapical
films,bite wing, occlusal films
J R 

  - Panoramic
films,,Computed
tomography,arthography,Magnetic
resonance imaging ,ateral
cephalometric films,Ñone scans


RŒ

— !j




JÑefore any
restorative
treatment,
pulpal health
must be
assessed

‡ Pulp testing is
often
performed
using and
electric pulp
tester
‡ A tooth with a
porcelain
jacket crown
presents
obvious
difficulties for
electric pulp
testing due to
non
conductivity of
porcelain
J If such a tooth is suspected to be
non vital and the matter cannot be
resolved with the aid of the
radiograph ,it may be necessary to
cut a small access hole through the
cingulum area to the dentine

J If the tooth proves vital this can be
filled with composite
J If it proves to be non vital then the
access hole serves necessary root
canal treatment

JResponse to
cold stimulus
can a simple
method of
determining
vitality

J A small pellet
of cotton wool
is soaked in
highly volatile
ethyl chloride


 

c
 


J They must be accurate
reproductions of maxillary and
mandibular arches

J Articulated diagnostic casts can
provide a great deal of information
for diagnosing problems and
arriving at a treatment plan

J They allow an
unobstructed view
of edentulous
spaces and
accurate
assessment of
span length as
well as
occlusogingival
dimension
J The length of the abutment can be
accurately gauged to determine
which preparation will provide
adequate retention and resistance

J The true inclination of abutment
teeth will also become evident,so
problems in a common path of
insertion can be anticipated

J ^urther analysis of occlusion can be
conducted
J Occlusal discrepancies
J Discrepancies in occlusal plane
J Teeth that have supra erupted can
be spotted
J A thorough evaluation of wear
facets, their number size and
location
c
RjR

 c

— !Œ
Œ
J When the history and examination
are completed, a differential
diagnosis is made

J The practitioner should determine
the most likely causes of the
observed condition(s and record
them in order of probability

J A definitive diagnosis can usually
be developed after such supporting
evidence has been assembled

J A typical diagnosis will condense
the information obtained during the
clinical history taking and
examination

Vj!— !Œ
Œ
J The prognosis is an estimation of
the likely course of a disease

J It can be difficult to make, but its
importance to patient understanding
and successful treatment planning
must nevertheless be recognized

J The prognosis of dental disorders,
is influenced by general factors(age
of the patient, lowered resistance of
the oral environment and local
factors(forces applied to a given
tooth, access for oral hygiene
measures

J ^or example, a young person with
periodontal disease will have a
more guarded prognosis than an
older person with the same disease
experience

J In the younger person, the disease
has followed a more virulent course
because of the generally less-
developed systemic resistance;
these facts should be reflected in
treatment planning
J ^ixed prostheses function in a
hostile environmentr the moist oral
environment is subject to constant
changes in temperature and acidity
and considerable load fluctuation

JA comprehensive clinical
examination helps identify the likely
prognosis

J All facts and observations are first
considered individually and then
correlated appropriately

 —


 

J The overall caries rate of the
patient¶s dentition indicates future
risk to the patient if the condition is
left untreated

J Systemic problems analyzed in the
context of the patient¶s age and
overall health provide important
information
J Other important factors in
determining overall prognosis are
the history and success of previous
dental treatments

J If a patient¶s previous dental care
has been successful over a period
of many years, a better prognosis
can be anticipated than when
apparently properly fabricated
prostheses fail or become
dislodged within a few years of
initial placement


 

J The observed vertical overlap of the
anterior teeth has a direct impact on
the load distributed in the dentition
and thus can have an impact on the
prognosis

J Impactions adjacent to a molar that
will be crowned may pose a serious
threat in a younger individual in
whom additional growth can be
anticipated
, but it may be of lesser
concern in an older individual

J Individual tooth mobility, root
angulation, root morphology, crown-
to-root ratios, and many other
variables all have an impact on the
overall fixed prosthodontic
prognosis

Ô 

JDiagnosis is a summation of
the observed problems and
their underlying etiologies

JAlso, the overall outcome and
prognosis may be adversely
affected